I wanted to reflect on an announcement that’s seemed so outlandish, so inconceivably short-sighted, that I fear that the majority of our profession may not have wrapped their heads around the likely consequences.
I’m talking about ‘111 first‘ being rolled out across the country. No patient should attend emergency departments, except in the most serious circumstances, unless they have phoned 111 and been triaged first. After all, 111 has a reputation for efficiently, and appropriately, triaging patients. What could possibly go wrong? People sitting at home with heart attacks and strokes waiting for ten hours? Such stories are going to become commonplace.
There are several strands to my horrified alarm at these announcements. One is that the national change in policy is based upon the presumption that general practice has the capacity to deal with a significant extra amount of semi-urgent care. What do you think all those 111/CCAS slots have sprung up onto your appointment screen for? For fun?
We’ll have the appointments booked onto our screens (after all, we have the capacity to offer dozens more appointments than we already are), and will be expected to contact the patients within two hours.
If patients are being diverted from emergency departments to another service in this way, NHS England has an absolute duty to ensure that the service they’re sending patients to has the capacity to cope. After all, there is little use in directing 20,000 passengers from a sinking cruise ship onto a lifeboat designed to hold 100.
The passengers will still die, only in a different vessel. The Royal College of Emergency Medicine may have embraced the ‘111 first’ model, but they have their own sinking cruise ship to think about.
My second concern is around those many patients who will undoubtedly be inappropriately triaged. As doctors, we know very well that not all emergency presentations appear with flashing lights, broken bones, and blood. There are plenty of life-threatening events that occur with relatively innocuous symptoms.
Take the mild chest pain of an 80-year old, which heralds a myocardial infarction. That subtle loss of speech or vision which betrays a stroke. The list goes on – you know how easy it is to misdiagnose or overlook a severe illness when symptoms are described over the phone. These changes will lead to many critically ill patients being left to deteriorate at home, before the overwhelmed GP phones a few hours later, only to discover that they now need an emergency ambulance to transport them to A&E. But the ambulances are full, so they will have an even longer wait…
I can understand not wishing to have crowding in emergency departments, I really can. But it wouldn’t be beyond the wit of man to encourage most to wait in their cars, using a mobile phone based ticketing system, and erect marquees to provide socially distanced waiting areas for the rest. At least then, when someone is at death’s door, they’re significantly closer to the doors of A&E.
My third concern is based on the secrecy around these large scale changes. Our health secretary has gleefully announced this masterful innovation, of switching to a remote triage model for emergency departments. Only he forgot to publish any data from the pilot areas, to show us exactly where the patients are going to be diverted to – never mind ensuring that funding and staff resources follow the patients.
Even if only 25% of those triaged by 111 were diverted to their GPs, this will serve to further destroy the remnants of our service. A system-wide change on this scale must absolutely be undertaken after careful piloting, and transparent negotiations with all stakeholders. For instance, we know that it is the GPs serving the most deprived areas whose patients have the highest rates of emergency department attendance. These surgeries, already under disproportionate strain, will find it even harder to provide good quality services for their patients. These changes will inevitably increase health inequalities for the most deprived.
And now we know what will be the final nail in the coffin for us this winter. We are to lead the nation’s response the Covid pandemic, by administering millions of vaccines to the comorbid and elderly, in an operation that would be baulked at by the military. Has someone failed to notice that we might be busy doing something else important? I predict that we too are going to be rather busy in the coming months, picking up the pieces of their incompetence.
It’s essential that NHS England shows the profession some respect, and publishes the report from the pilot areas of the ‘111 first’ model. How many extra patients should we be steeling ourselves for? And how exactly are we going to deal with the extra demand, when we are ‘pragmatically’ reducing our workload elsewhere in order to deliver the vaccine? When the reports start rolling in of our patients dying in avoidable circumstances, while waiting for a 111 call-back, can we be told who exactly was the mastermind behind this? Will they be held liable for manslaughter? My prediction is, unless someone sensible puts the brakes on this scheme, there is about to be a car crash.
Dr Katie Musgrave is a newly qualified GP in Plymouth and quality improvement fellow for the South West
yup, I emailed the Devon MPs, NHS England, the cross Parliamentary cross Party Covid group, the cross Parliamentary Health and Social care committee, the BMA, RCGP this very concern. Don’t worry though, we are also planned for Long Covid clinics too. But if we don’t see enough face to face appointments we will be investigated. Looking forward to winter season
This is incredibly well written. Well done Dr Musgrave.
Very good article & far too much system change with little understanding of the implications, with real risk to patients.
As well as pilots, what do patients /public actually think?
Take it up with your BMA representatives, who agreed to 111 appointment booking as part of your GMS contract obligations.
Spot on Dr Musgrove
AS A HOSPITAL MEDICAL DIRECTOR ONCE SAID TO ME AT MID NIGHT ” I’M SURE YOU’LL MANAGE”
Nail-on-the-head, Dr Musgrove. Trying to figure our how and by whom these schemes originate is trying to understand the non-understandable.
To play devils advocate – whilst I can’t speak for other areas of the country , on my patch the service is being provided by experienced GPS who already work in urgent care
There are a significant number of patients who are struggling to access primary care and wrongly perceive that their GP is shut . Most can be managed with a telephone consultation and signposting , those with urgent matters are booked directly into an appointment in the ED/UTC . Most signposting back to the GP is for routine matters that need diagnostic work up -very rarely ‘within 2 hours’ appointments.
And, avoiding pooling or packed ED waiting rooms during a pandemic can only be a good thing.
I agree that the service needs to be carefully audited – I would also always argue for better funding to increase daytime GP capacity but as things stand daytime GP is full – we cannot safely deal with more than 40 patients a day plus covid and many GP colleagues admit that they are relieved that the pressure to deal with yet more patient call backs in a busy day is being dealt with by a parallel service
The status quo was just not sustainable BC.
111 and ccas has been running now for many months and it became clear in the summer months that the service was transferring to non covid work. The mystery here is who is driving NHS policy and why have the BMA and RCGP been so quiet on the subject, one assumes as they were not involved?
I suspect most of us do not know the process involved-I think a non clinical call handler is meant to detect immediate life threatening conditions and send direct to a/e via the DOS as cat 1 ambulance or a cat 2 ambulance. Those left are then passed to a 111 clinician – not sure if that is the ccas service or another parallel but similar. That service can now also prescribe.
One of my workplaces in a UTC also gets calls from 111, some appropriate some frankly daft but that is because there appears no capacity in the more appropriate services i think. The main question remains though who has drawn up and commissioned this service; presumably not each ccg
What has this to do with a vaccine??
Excellent article. The only quibble is that there is no way a 2-hour disposition can contractually be transferred to primary care – there is nothing allowing this in existing GMS, PMS, or APMS contracts. In London, we have made the point quite forcefully that if 111 thinks it’s a 2-hour disposition, it can’t just be chucked at primary care (although of course if there’s a free slot within that timeframe, great).
Very important that other areas point this out and decline to see any/all of these 2-hour calls. They are manifestly unsuitable for primary care.